Incisional hernia of [abdominal wall] (disorder) - v1.0

Yongsheng Gao I have made changes to this template and placed it back in review for you. I have changed the title and the concepts this template applies to. The reason for this is parastomal hernias are not due to impaired wound healing (https://www.uptodate.com/contents/parastomal-hernia) I discussed this with Paul Amos. Parastomal hernias will be noted for further work. Regards, Cathy

Hi Bruce Goldberg Cathy Richardson , I think due to impaired wound healing is a common cause of incisional hernia. It would be too restrict to assume that all incisional hernias are caused by impaired wound healing. The examples of some other causes are mentioned in https://www.hopkinsmedicine.org/healthlibrary/conditions/digestive_disorders/incisional_hernia_22,IncisionalHernia   As a result of the change for due to relationship, incisional hernia would be classified as a complication of clinical finding rather than complication of surgical procedure. It would be correct for the cause of impaired wound healing, but might not be right for other causes.

The second problem is a general issue for modeling surgical procedure vs. incision procedure. Many surgical procedures involve incision but they are not explicitly represented, e.g. repair or excision of anatomical structures within abdominal cavity. It is a big and complicated task to explicitly model all surgical procedures that involve incision. The model 'after incision procedure' would not classify incisional hernia after appendectomy as a subconcept of incisional hernia.  So, I think after = surgical procedure would be sufficient. 

Let's talk about this at the next Editor's call this week. 

Cheers,

Yong

Hi Yongsheng Gao Cathy Richardson. Regarding the first statement, I think the causes of incisional hernia mentioned in the Hopkin's article all result in impaired wound healing which is the ultimate cause of the hernia as supported by the following statement in UpToDate:

"Comorbid conditions, including old age, obesity, smoking, malnutrition, immunosuppressive therapy, and connective tissue disorders, among others, can impede normal wound healing and increase the risk for incisional hernia [12,13]. (See "Risk factors for impaired wound healing and wound complications)." 

Perhaps though including impaired wound healing in the definition is overmodeling as impaired wound healing is inherent in the definition of incisional hernia. I tried including a 3rd role group with associated morphology = 103681003 |Impaired tissue repair (morphologic abnormality)| + finding site = 83908009 |Abdominal wall structure (body structure)|but no additional parents were inherited. A similar argument may be made for the case of using surgical procedure instead of incision as the value of both due to and after. Incision is inherent in the definition of a surgical procedure as all surgical procedures must start with an incision.

Yongsheng Gao Given the comments here and the discussion on the Editors Call, the template has been revised. Would you please review and sign off. Thanks, Cathy

Thanks Cathy Richardson, I have simplified the rules for descriptions. The FSNs for large/small intestine have been updated in production to support the automation. The template is ready for implementation now. Cheers, Yong

I am just getting to reviewing this and have a few questions:  Is it the intent of this class of concept to specify the entire natural history of the disorder or just to state the fact that a hernia occurred due to impaired wound healing.  How much additional information do we gain by stating how the incision/wound was made.  At a minimum, the DUE TO relationship should refer to 271618001 |Impaired wound healing (finding)|, not the surgical procedure.  The impaired wound healing did occur after an incision.

The current modeling of 414474001 |Incisional hernia of anterior abdominal wall (disorder)| in the daily build browser seems to reflect my thinking.  What is the reasoning for changing that pattern?

One other issue I am seeing involves assigning a parent of Sequela. Using an after relationship to incision which is a surgical procedure makes this a surgical sequela but we surgeons define sequelae as expected outcomes. This should just be a postoperative complication imo.

Hi Bruce Goldberg, Yongsheng Gao and Jim Case

I’d pushed forward with this one as while it is a bit complex, it was started before we descoped on QI and it had been well developed by the time descoping occurred. Each time we’ve tweaked this, I had thought it wasn’t much work to get it across the line, so pushed forward on it but that doesn’t seem to be the case.

Looking at the comments here, do we want to get this one across the line or place it on hold? Either way I’ll check the incisional hernia content to support correct subsumption. The parastomal hernias need a bit more work and have been put on hold for now but will also be checked for subsumption.

If moving it across the line:

Sequela: As noted by Bruce- remove that relationship.

In doing that, we need the due to but the after relationship is allowable but not required.

Due to = Impaired wound healing is not correct for all incisional hernias. Parastomal hernias are a type of incisional hernia which are not due to impaired wound healing https://www.uptodate.com/contents/parastomal-hernia 

While without the incision there wouldn’t be an incisional hernia, the incision usually forms part of a surgical procedure. Given this, surgical procedures are not subtypes of incision and an incisional hernia is a complication of a surgical procedure. Due to = << surgical procedure captures this and also supports correct subsumption.

In noting this most subtypes of Complication of surgical procedure are primitive at present so where the concept is present e.g. 111751003 |Complication of external stoma of gastrointestinal tract (disorder)| that would need to be the proximal primitive parent. A parastomal hernia (where the stoma is created in the gastrointestinal tract) would be a subtype of this.

The after attribute is required to identify this as a post op complication. Same logic as above applies here.  

Regards,

Cathy

Paul Amos  -as doing the reviews.

Good point about parastomal hernias being incisional hernias that are not related to impared wound healing

Bruce

Good catch on the parastomal hernia.  However, I am still of the opinion that we are overmodeling by saying the incision hernia is DUE TO the procedure.  The procedure is not causal, nor do I think it is really in the causal chain due to the fact that the vast majority of abdominal surgeries do not result in an incisional hernia.  The surgeon view of Sequela and Complication are problematic as they go against the "normal" view of complication.  I think we need a more parsimonious view of what is needed to get proper classification rather than trying to model all possible relationships.  So we need to agree on the following things:

An incisional hernia is:

• a clinical condition that occurs AFTER a surgical procedure - 385486001 |Postoperative complication (disorder)|  is defined with an AFTER relationship, but not a DUE TO (therefore a DUE TO is not needed for them to classify under Postoperative complication)
• because of the surgeon view of sequela, it is a Post-operative complication, but not a sequela
• while an incisional hernia requires that a surgical procedure (i.e. incision) be performed, the hernia itself is not DUE TO the procedure, but to the presence of an incision or a stoma
• In cases where the incisional hernia is a result of impaired wound healing, then the DUE TO relationship should be added (not for the top-level concept 236037000 |Incisional hernia (disorder)|
• The current modeling of 236048007 |Parastomal hernia (disorder)| includes a DUE TO Impaired wound healing relationship.  This needs to be corrected
• Modeling of parastomal hernia "could" be defined using a DUE TO 302918009 |Disorder of stoma (disorder)| (bit I think that is a stretch)

In short, I think we need to test the need for a DUE TO relationship in all cases (except for the impaired healing types), given the fact that we can get these to classify under post-operative complication without having it, and we can distinguish parastomal hernias by the finding site.  I also think we should closely evaluate the need for current existing primitive postoperative complications such as  111751003 |Complication of external stoma of gastrointestinal tract (disorder)| given their limited clinical usefulness (too vague).  This is a difficult area, so we should try to trim it down to just what is essential to provide the always and necessarily true aspects and proper classification

Yongsheng Gao Please review this template. I'd prefer to exclude parastomal hernias at this point as they can't be defined. There are are issues with the finding site -given the parastomal aspect plus the appropriate stoma procedure concept is not aways present. Given our QI focus at this point the parastomal hernias have been noted for further work at the next stage. Thanks, Cathy. 

Cathy Richardson , I have updated range for course and changed the cardinality to 1..1 for role group 2. This would be a specific template for abdominal incisional hernia. It is reflected in the template name. Cheers, Yong

Hi Yongsheng Gao The concept 19203006 |Structure of abdominal viscus (body structure)| is going to be inactive in Jan 31th 2020 release, Could you please replace with the other one? Thanks

https://authoring.ihtsdotools.org/browser/?perspective=full&conceptId1=19203006&edition=MAIN&release=&languages=en